Partial Foot Research Articles

Pedorthic management of the diabetic foot

Conservative pedorthic management of the diabetic foot has been shown to be an effective method to prevent ulcers, amputations, and re-amputations. This article exhibits why and how pedorthics plays such an important role via modalities such as footwear, shoe modifications, custom foot orthoses, and partial foot prostheses. The objective of this article is to demonstrate how pedorthics has been shown to be an integral part of conservative diabetic foot care. The authors' goal was to educate the reader about the different modalities that are available for use. This article is based largely on review of previously published research and scholarly articles, augmented by the more than 60 years of pedorthic and orthotic clinical experience of the authors. Approximately 60 journal articles and book chapters were reviewed by the authors. Articles were located via online resources such as PubMed as well as the authors' own libraries. It was repeatedly noted that pedorthic modalities such as shoes, foot orthoses, and shoe modifications may be utilized in the treatment and prevention of diabetic foot wounds and other complications. Pedorthic devices may be successfully integrated into a comprehensive treatment plan for patients with diabetes and foot ulcers. This information is of special interest to those who treat patients with diabetes. The article demonstrates the efficacy of pedorthic intervention through the compilation and review of relevant previously published data.

Lower-limb amputation and body weight changes in men.

Little is known about the relationship between lower-limb amputation (LLA) and subsequent changes in body weight. We conducted a retrospective cohort study using clinical and administrative databases to identify and follow weight changes in 759 males with amputation (partial foot amputation [PFA], n = 396; transtibial amputation [TTA], n = 267; and transfemoral amputation [TFA], n = 96) and 3,790 nondisabled persons frequency-matched (5:1) on age, body mass index, diabetes, and calendar year from eight Department of Veterans Affairs medical care facilities in the Pacific Northwest. We estimated and compared longitudinal percent weight change from baseline during up to 39 mo of follow-up in participants with and without amputation. Weight gain in the 2 yr after amputation was significantly more in men with an amputation than without, and in men with a TTA or TFA (8%-9% increase) than in men with a PFA (3%-6% increase). Generally, percent weight gain peaked at 2 yr and was followed by some weight loss in the third year. These findings indicate that LLA is often followed by clinically important weight gain. Future studies are needed to better understand the reasons for weight gain and to identify intervention strategies to prevent excess weight gain and the deleterious consequences that may ensue.

Evaluation of the Sagittal Saw Blade as an Intraoperative Fomite During Diabetic Foot Surgery

Surgical site infection is a major potential complication of all operative interventions, and the diabetic foot is particularly at risk for bacterial recontamination and infectious sequelae. The objective of this study was to identify whether the sagittal saw blade used during partial foot amputations and diabetic foot debridements carries the potential to serve as a bacterial fomite. We physically cultured the sagittal saw blade during 20 foot debridements involving the resection of bone in patients diagnosed with a diabetic foot infection. The culture was taken after the initial debridement and during the irrigation phase of the procedure. We observed 16 positive routine intraoperative culture results, with positive saw blade culture results in 15 (93.8%; 15/16) of these cases. In 14 (93.3%; 14/15) of these cases, the saw blade culture grew at least one of the same bacteria as our other routine intraoperative cultures. We observed 4 negative routine intraoperative culture results, with negative saw blade culture results in 3 (75.0%; 3/4) of these cases. This results in agreement between routine intraoperative cultures and saw blade culture of 85.0% (17/20). The results of this investigation demonstrate that the sagittal saw blade used for osseous resection during diabetic foot debridements and partial foot amputations carries the potential for intraoperative bacterial transmission. We recommend changing at least the sagittal saw blade if more bone is resected following irrigation, particularly if it is used to obtain a "clean margin" for microbiological or histological examination. Therapeutic, Level IV: Case series.

Large lumbar anurysmal bone cyst presenting as an abdominal mass. Management and outcome

Background Data: Aneurysmal bone cysts (ABCs) of the spine account for 12 to 30% of all ABC cases. They mostly occur in the lumbar vertebrae, followed by the thoracic, cervical, and sacral vertebrae. Despite being benign, they can be locallyexpansive and destructive, and can result in pathological fractures of the vertebrae and neurological complications. Treatment modalities include surgical resection, radiotherapy, and embolization with reconstruction. Purpose: To report on a rare case of very large aneurysmal bone cyst originating from the body and the posterior arch of L3 vertebrae and extending from the paraspinal sub-cutaneous tissue posteriorly to the anterior abdominal wall anteriorly and pushing the kidney up and explaining the way of management of such cases. Study Design: Case report and review of literature.Patient and Methods: An 18years old female patient presented with back pain, right lower limb numbness and partial foot drop together with a big abdominal mass. A thorough general and neurological examination proceeded by properhistory taking including family history and previous trauma were done. Radiological workup was done in the form of plain X-ray, CT scan, and MRI. Total excision and reconstruction was performed under general anesthesia through a posterior only approach. Results: Post operatively the patient recovered nicely without any neurological deficits within 2 weeks. Post operative CT showed total excision, adequate reconstruction and trans-pedicular screw fixation. This patient was followed up clinically for 8 months till now with very good neurological condition. Conclusion: Proper diagnosis and adequate surgical techniques are mandatory for proper surgical excision of such a very big ABC especially if highly vascular.(2014ESJ083)

Technical tip: Percutaneous bone shaving and ulcer endoscopy to manage abnormal pressure point of the sole

Abnormal plantar pressure can follow post-traumatic foot deformity, Charcot neuroarthropathy and partial foot amputations. Surgery is indicated if the condition does not improve with orthotic treatment. We describe the techniques of percutaneous shaving of the plantar bone prominence and ulcer endoscopy to manage abnormal pressure points under the sole of the foot.

Primary closure of elective toe amputations in the diabetic foot--is it safe?

Toe amputation is the most common partial foot amputation. Controversy exists regarding whether to primarily close toe amputations or to leave them open for secondary healing. The purpose of this study was to evaluate the results of closed toe amputations in diabetic patients, with respect to wound healing, complications, and the need for further higher level amputation. We retrospectively reviewed the results of 40 elective or semi-elective toe amputations with primary closure performed in 35 patients treated in a specialized diabetic foot unit. Patients with abscesses or necrotizing fasciitis were treated emergently and were excluded. Patients in whom clean margins could not be achieved due to extensive cellulitis or tenosynovitis and patients requiring vascular intervention were excluded as well. Outcome endpoints included wound healing at 3 weeks, delayed wound healing, or subsequent higher level amputation. Out of 40 amputations, 38 healed well. Thirty amputations healed by the time of stitch removal at 3 weeks and eight had delayed healing. In two patients the wounds did not heal and subsequent higher level amputation was eventually required. In carefully selected diabetic foot patients, primary closure of toe amputations is a safe surgical option. We do not recommend primary closure when infection control is not achieved or in patients requiring vascular reconstruction. Careful patient selection, skillful assessment of debridement margins and meticulous technique are required and may be offered by experienced designated surgeons in a specialized diabetic foot unit.

Ergotism and factitious hypotension associated with interaction of ergotamine with CYP3A4 inhibitors

Background. Although uncommon, severe ergotism continues to occur. The purpose of this study is to describe causes and clinical effects of ergotism in recent years. Methods. This is an observational case series with data obtained retrospectively from all patients with ergotism referred to Ramathibodi Poison Center in Bangkok, Thailand from January 2006 to August 2013. Result. Twelve cases of ergotism were identified. All cases involved ergotamine 1 mg/caffeine 100 mg combination tablets. Nine cases (75%) were precipitated by drug–drug interactions with CYP3A4 inhibitors. The other cases involved suicidal attempt (2 cases) and pediatric unsupervised ingestion (1 case). Ten patients (83%) had signs of peripheral vascular insufficiency. Five of these patients initially had factitiously low or unmeasurable blood pressure using non-invasive technique and had paradoxical increase following intravenous vasodilator administration. Two patients required partial foot amputations due to gangrene. Two patients, including a 15-month-old boy with an unsupervised ingestion, died. Discussion. In this series, most cases of severe ergotism were associated with interaction with CYP3A4 inhibitors, which increase ergotamine bioavailability. Factitious low blood pressure in these cases was likely caused by severe vasospasm. Conclusion. Critical ergotism continues to occur in Thailand, most commonly associated with the drug–drug interactions.

Partial foot amputation may not always be worth the risk of complications

Partial foot amputation may not always be worth the risk of complications

Treatment of Postoperative Lower Extremity Wounds Using Human Fibroblast–Derived Dermis

Human fibroblast-derived dermis skin substitute is a well-studied treatment for diabetic foot ulcers; however, no case series currently exist for its use in healing postoperative wounds of the lower extremity. A retrospective analysis was conducted on 32 lower extremity postoperative wounds treated weekly with human fibroblast-derived dermis skin substitute. Postoperative wounds were defined as a wound resulting from an open partial foot amputation, surgical wound dehiscence, or nonhealing surgical wound of the lower extremity. Wound surface area was calculated at 4 and 12 weeks or until wound closure if prior to 12 weeks. Postoperative wounds treated with weekly applications showed mean improvement in surface area reduction of 63.6% at 4 weeks and 96.1% at 12 weeks. More than 56% of all wounds healed prior to the 12-week endpoint. Additionally, only one adverse event was noted in this group. This retrospective review supports the use of human fibroblast-derived dermis skin substitute in the treatment of postoperative lower extremity wounds. This advanced wound care therapy aids in decreased total healing time and increased rate of healing for not only diabetic foot wounds but also postoperative wounds of the lower extremity, as demonstrated by this retrospective review.

Physical activity barriers and enablers in older Veterans with lower-limb amputation.

Little is known about the types of physical activities that older individuals with lower-limb loss perform, correlates of regular physical activity (PA), and barriers and facilitators to PA. We conducted an exploratory study in 158 older Veterans from the Pacific Northwest with a partial foot (35%), below-knee (39%) and above-knee (26%) amputation. Ninety-eight percent of survey respondents were male, on average 65 yr of age and 15 yr postamputation; 36% of amputations were trauma-related. The most commonly reported physical activities were muscle strengthening (42%), yard work and/or gardening (30%), and bicycling (11%). Forty-three percent were classified as physically active based on weekly moderate- and vigorous-intensity PA. History of vigorous preamputation PA was positively associated with being active, while low wealth and watching ≥5 h/d of television/videos were inversely associated. While pain- and resource-related barriers to PA were most frequently reported, only knowledge-related and interest/motivation-related barriers were inversely associated with being active. Family support and financial assistance to join a gym were the most commonly reported factors that would facilitate PA. To increase PA in the older amputee population, interventions should address motivational issues, knowledge gaps, and television watching; reduce financial barriers to exercising; and consider involving family members.

Gyrate Erythema and Melanoma—A New Clinical Association

The authors present the case of a 65-year-old gentleman with a 2.6-mm Breslow thickness melanoma on the lower limb. During his treatment, he underwent several operations including a partial foot amputation. At clinical review, he was noted to have developed an unusual rash. This rash, an annular and gyrate erythema, has never been described before in relation to melanoma, and is sometimes seen in the presence of paraneoplastic processes. Highlighting this new association may enable clinicians to understand and appreciate melanoma better in the future.

Incidence of lower limb amputation in Australian hospitals from 2000 to 2010

Contemporary literature reports that the incidence of lower limb amputation has declined in many countries. This impression may be misleading given that many publications only describe the incidence of lower limb amputations above the ankle and fail to include lower limb amputations below the ankle. To describe trends in the incidence of different levels of lower limb amputation in Australian hospitals over a 10-year period. Descriptive. Data describing the age-standardised incidence of lower limb amputation were calculated from the Australian National Hospital Morbidity database and analysed for trends over a 10-year period. The age-standardised incidence of lower limb amputation remained unchanged over time (p = 0.786). A significant increase in the incidence of partial foot amputations (p = 0.001) and a decline in the incidence of transfemoral (p = 0.00) and transtibial amputations (p = 0.00) were observed. There are now three lower limb amputations below the ankle for every lower limb amputation above the ankle. While the age-standardised incidence of all lower limb amputation has not changed, a shift in the proportion of lower limb amputations above the ankle and lower limb amputations below the ankle may be the result of improved management of precursor disease that makes partial foot amputation a more commonly utilised alternative to lower limb amputations above the ankle. Clinical relevance This article highlights that although the incidence of lower limb amputation has remained steady, the proportion of amputations above the ankle and below the ankle has changed dramatically over the last decade. This has implications for how we judge the success of efforts to reduce the incidence of lower limb amputation and the services required to meet the increasing proportion of persons with amputation below the ankle.

Intrinsic Foot and Ankle Flaps

Foot and ankle soft tissue reconstructions often require a team approach, which at the minimum includes a wound care team, a vascular surgeon, a foot and ankle surgeon, a plastic surgeon, an infectious disease specialist, an endocrinologist, and a prosthetist. The initial factors that always need to be addressed include establishing adequate blood flow, controlling infection, and offloading the foot. Blood flow status has to be assessed to ensure good blood flow to the angiosome(s) where the wounds are located and where reconstruction is to occur. Wounds then need to be accurately assessed, debrided, and cultured. The repair is then dictated by the ultimate residual function of the foot and ankle and hence focused on how the wound can be closed in a biomechanically stable construct without recurrent breakdown. This may involve skeletal manipulation, tendon lengthening and/or partial foot and leg amputations. In this chapter, the main intrinsic foot flaps are described to expand the range of reconstructive soft tissue options that plastic surgeons can use to close small defects. The details of the individual flap dissections are described in several atlases on flaps. More importantly, repeated cadaver dissection of these flaps, emphasizing the blood supply, is the most reliable way to become facile in their use.

SIMULTANEOUS BILATERAL RUPTURE OF ACHILLES TENDON ASYMPTOMATIC POSTENDINOPATHY

IntroductionRupture of Achilles tendon is the most common among those taking place in the lower extremities, being twice as common in men than in women between 30–50 years old and...

Noninvasive Arterial Studies Including Transcutaneous Oxygen Pressure Measurements with the Limbs Elevated or Dependent to Predict Healing After Partial Foot Amputation

Noninvasive arterial studies have been used to determine level of amputation. The objective of this study was to examine each component of the noninvasive arterial studies to determine optimal cut points to predict healing and to evaluate whether physiologic maneuvers could improve the utility of transcutaneous oxygen pressure (TcPO2) values to predict healing of partial foot amputation. The authors conducted a retrospective, observational study of 307 patients who underwent partial foot amputation and had noninvasive arterial studies in the perioperative period. The TcPO2 values were significantly predictive of healing. Specifically, a cut point TcPO2 value of 38 mm Hg had a sensitivity and a specificity of 71% for predicting healing or failure. The optimal cut point was mostly unaffected by patient characteristics. The addition of noninvasive arterial studies recorded in a position with the limb elevated improved prediction in the subgroup with supine TcPO2 values of 38 mm Hg or lower. The findings of this study validate previous reports and confirm that TcPO2 measurements are valuable to more accurately determine the correct amputation level and, in turn, obtain better outcomes. TcPO2 measurements may provide better prognostic value than do ankle-brachial indices for healing after partial foot amputation. TcPO2 measurements are useful but should not be used in isolation to make treatment decisions regarding amputation level.

Deliberations About the Functional Benefits and Complications of Partial Foot Amputation: Do We Pay Heed to the Purported Benefits at the Expense of Minimizing Complications?

While discussion about the benefits and complications of partial foot amputation (PFA) is not new, much of it has hinged on anecdotal evidence and led to the popular view that the risk of complications and secondary amputation is reasonable when weighed against the perceived benefits associated with maintaining the ankle joint and residual foot length, including more normal walking, reduced energy expenditure, and improved quality of life. The research evidence makes it difficult not to question whether these benefits are valid and worth striving to achieve. When you consider that persons who undergo PFA are typically in the later years of their life and have limited mobility, it raises the question of whether we place too much emphasis on achieving the purported functional benefits of PFA and too little emphasis on achieving primary wound healing and mitigating the high rates of complications and subsequent amputation. If further research supports what we see emerging in the evidence, there will be a case to be made for selecting the level of PFA based primarily on the potential for wound healing, rather than trying to strike a balance with the perceived functional benefits. This may mean that transtibial amputation is preferable in many cases, given the lower rates of complications and secondary amputation, very similar function in terms of walking and energy expenditure, and similar lived experience of limb loss when compared with persons with PFA. Further research is needed to better understand the complications and benefits of PFA to make this a more viable, first-and-final amputation procedure.

Foot Care

Foot Care

Reconstructive and prosthetic options for the wounded warrior

A recent estimate of wounded from the Afghanistan war is close to 17,000 and from the Iraq war over 30,000. Extremity trauma is the one of the hallmark injuries from these conflicts. The long-term effects of this number of extremity-injured patients on our military and civilian health care systems is unknown. The relative severity, if amputation rate can be used as a surrogate, is significantly higher than in civilian trauma. In this article, we discuss the most current management strategies used in these complex patients and the myriad of lower extremity disease they experience. We also discuss a new “standard” for patients with severe lower extremity trauma. Previous expectations were to return patients to their preinjury level of function with limb retention. Now, the new expectation of this group of patients is to recover in a time frame and function level equivalent to a below knee amputee, which is a more accelerated course. Several advances have been made in an effort to offer similar functional results to these severely injured patients to include the gradual expansion muscle (GEM) flap, which corrects soft-tissue defects as well skeletal defects without the use of free-tissue transfer. Another significant advance is the Intrepid Dynamic Exoskeleton Orthosis (IDEO), which is a plantarflexion powered carbon fiber ankle-foot orthosis that allows patients with limb salvage the opportunity to return to high-impact activities. Other germane topics reviewed include management of calcaneal fractures with severe soft-tissue injury, partial foot amputations, and elective amputations for the indication of pain.

Negative pressure wound therapy and the Government agenda

To compare the use of negative pressure wound therapy (NPWT) and conventional wound dressings in the treatment of diabetic foot wounds. This article reviews research that compares the two treatments on partial foot amputations, foot ulcers, infected wounds and dehisced post-surgical wounds.A systematic literature search was carried out using CINAHL, MEDLINE and the Cochrane Library to locate and critique key studies comparing NPWT and conventional wound dressings to determine their quality.NPWT was found to be more effective in treating diabetic foot wounds compared with conventional wound dressings. NPWT was quicker at forming granulation tissue, achieving wound closure, removing infection from foot ulcer beds and decreasing wound dimensions. Data also showed greater incidence of amputations in those patients treated with moist wound dressings.Findings suggest that NPWT could be used as a primary treatment for diabetic foot wounds. Factors such as cost effectiveness and patient acceptability may have an impact on this treatment and will need to be investigated in implementing NPWT into practice.

Partial Foot Amputation in Patients with Diabetic Foot Ulcers

Transtibial amputations (TTA) are performed for recalcitrant or infected ulcers of the midfoot, hindfoot, or ankle. This procedure results in decreased ambulatory status caused by increased oxygen demands and energy expenditure. Partial foot amputations have the advantage of being an end-bearing limb and require less work to walk, theoretically suggesting improved functional outcome. The purpose of this research was to examine the longevity, outcome, and mortality of partial foot amputations as an alternative to TTA. Retrospective chart review identified diabetic patients with transmetatarsal, Chopart's, and calcanectomy amputations for osteomyelitis or nonhealing ulcers. A control group consisted of diabetic patients who underwent TTA. A comparison between groups examined mortality, proximal ipsilateral reamputation, and a validated ambulatory functional outcome measure. Eighteen TTA patients were enrolled. The 5-year mortality rate was 0.45, one patient required reamputation, and the mean postoperative ambulatory score was 2.8. Twenty-one transmetatarsal patients were enrolled. The 5-year mortality rate was 0.30, two patients required reamputation, and the mean postoperative ambulatory score was 4.3. Ten Chopart's amputation patients were enrolled. The 5-year mortality rate was 0.36, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Seventeen partial calcanectomy patients were enrolled. The 5-year mortality rate was 0.69, six patients required reamputation, and the mean postoperative ambulatory score was 4.3. Sixteen total calcanectomy patients were enrolled. The 5-year mortality rate was 0.59, five patients required reamputation, and the mean postoperative ambulatory score was 3.3. TTA is associated with high morbidity and mortality, which suggests that the advantage of partial foot amputations should be investigated. Only transmetatarsal amputations at 1 and 3 years were statistically lower for mortality than TTA. Partial foot amputations at the other levels failed to show statistically improved survivorship. Transmetatarsal and Chopart's amputations had high ambulatory levels and the longest durability, which suggests that these amputations may provide some ambulatory advantage.